Download Level of Evidence: B

Antiplatelet
Therapy
Recommendations
(UPDATED)
DR MAHMOOD DARGAHI
INTERVENTIONAL CARDIOLOGIST
CLASS I
 1.
Aspirin should be administered to
UA/NSTEMI patients as soon as possible after
hospital
presentation
and
continued
indefinitely in patients not known to be
intolerant of that medication. (Level of
Evidence: A)
 2. Clopidogrel (loading dose followed by daily
maintenance dose) should be administered to
UA/NSTEMI patients who are unable to take
ASA because of hypersensitivity or major
gastrointestinal intolerance. (Level of
Evidence: A)
 3. In UA/NSTEMI patients with a history of
gastrointestinal bleeding, when ASA and
clopidogrel are administered alone or in
combination, drugs to minimize the risk of
recurrent gastrointestinal bleeding (e.g.,
proton-pump
inhibitors)
should
be
prescribed
concomitantly.
(Level
of
Evidence: B)
 4. For UA/NSTEMI patients in whom an
initial invasive strategy is selected, antiplatelet
therapy in addition to aspirin should be
initiated before diagnostic angiography
(upstream) with either clopidogrel (loading
dose followed by daily maintenance dose) or
an intravenous GP IIb/ IIIa inhibitor. (Level
of Evidence: A)
 Abciximab as the choice for upstream GP
IIb/IIIa therapy is indicated only if there is
no appreciable delay to angiography and
PCI is likely to be performed;
 otherwise, IV eptifibatide or tirofiban is the
preferre choice of GP IIb/IIIa inhibitor.
(Level of Evidence: B)
 5. For UA/NSTEMI patients in whom an
initial conservative (i.e., noninvasive) strategy
is selected , clopidogrel (loading dose followed
by daily maintenance dose) should be added to
ASA and anticoagulant therapy as soon as
possible after admission and administered for
at least 1 month (Level of Evidence: A) and
ideally up to 1 year. (Level of Evidence: B)
 6. For UA/NSTEMI patients in whom an
initial conservative strategy is selected, if
recurrent symptoms/ische-mia, HF, or serious
arrhythmias subsequently appear, then
diagnostic angiography should be performed.
(Level of Evidence: A),
 Either an intravenous GP IIb/IIIa inhibitor
(eptifibatide or tirofiban; Level of Evidence:
A) or clopidogrel (loading dose followed by
daily maintenance dose; Level of Evidence: A)
should be added to ASA and anticoagulant
therapy before diagnostic angiography
(upstream). (Level of Evidence: C)
CLASS IIA
 1. For UA/NSTEMI patients in whom an
initial conservative strategy is selected and
who have recurrent ischemic discomfort
with clopidogrel, ASA, and anticoagulant
therapy, it is reasonable to add a GP IIb/IIIa
antagonist before diagnostic angiography.
(Level of Evidence: C)
 2. For UA/NSTEMI patients in whom an
initial invasive strategy is selected, it is
reasonable to initiate antiplatele therapy
with both clopidogrel (loading dose followed
by daily maintenance dose) and an
intravenous GP IIb/IIIa inhibitor. (Level of
Evidence: B)
 3. For UA/NSTEMI patients in whom an
initial invasive strategy is selected, it is
reasonable to omit upstream administration
of an intravenous GP IIb/IIIa antagonist
before diagnostic angiography if bivalirudin
is selected as the anticoagulant and at least
300 mg of clopidogrel was administered at
least 6 h earlier than planned catheterization
or PCI. (Level of Evidence: B)
CLASS IIB
 For UA/NSTEMI patients in whom an
initial conservative (i.e., noninvasive)
strategy is selected, it may be reasonable to
add
eptifibatide
or
tirofiban
to
anticoagulant and oral antiplatelet therapy.
(Level of Evidence: B)
CLASS III
 Abciximab should not be administered to
patients in whom PCI is not planned. (Level
of Evidence: A)
Initial Conservative
Versus Initial
Invasive Strategies
(UPDATED)
Class I
 1. An early invasive strategy (i.e., diagnostic
angiography with intent to perform
revascularization)
is
indicated
in
UA/NSTEMI patients who have refractory
angina or hemodynamic or electrical
instability (without serious comorbidities
or contraindications to such procedures).
(Level of Evidence: B)
 2. An early invasive strategy (i.e., diagnostic
angiography with intent to perform
revascularization) is indicated in initially
stabilized UA/NSTEMI patients (without
serious comorbidities or contraindications
to such procedures) who have an elevated
risk for clinical events (Level of Evidence:
A)
Elevated risk for clinical events
 Recurrent angina or ischemia at rest or with low



level activities despite intensive medical therapy
Elevated cardiac biomarkers (TnT or TnI)
New or presumably new ST-segment depression
Signs or symptoms of HF or new or worsening
mitral regurgitation
High-risk findings from noninvasive testing
 Hemodynamic instability
 Sustained ventricular tachycardia
 PCI within 6 months
 Prior CABG
 High risk score (e.g., TIMI, GRACE)
 Reduced left ventricular function (LVEF less
than 40%)
CLASS IIB
 1. In initially stabilized patients, an initially
conservative (i.e., a selectively invasive)
strategy may be considered as a treatment
strategy for UA/NSTEMI patients (without
serious comorbidities or contraindications to
such procedures) who have an elevated risk for
clinical events) including those who are
troponin positive. (Level of Evidence: B)
 The
decision to implement an initial
conservative (vs. initial invasive) strategy in
these patients may consider physician and
patient preference. (Level of Evidence: C)
 2. An invasive strategy may be reasonable in
patients with chronic renal insufficiency (Level
of Evidence: C)
CLASS III
 1. An early invasive strategy (i.e., diagnostic
angiography with intent to perform
revascularization) is not recommended in
patients with extensive comorbidities (e.g.,
liver or pulmonary failure, cancer), in whom
the risks of revascularization and comorbid
conditions are likely to outweigh the benefits
of revascularization. (Level of Evidence: C)
 2.
An early invasive strategy (i.e.,
diagnostic angiography with intent to
perform
revascularization)
is
not
recommended in patients with acute chest
pain and a low likelihood of ACS. (Level of
Evidence: C)
 3. An early invasive strategy (i.e., diagnostic
angiography with intent to perform
revascularization) should not be performed
in patients who will not consent to
revascularization regardless of the findings.
(Level of Evidence: C)
Long-Term Medical
Therapy and
Secondary
PreventionWarfarin
Therapy (UPDATED)
CLASS I
 Use of warfarin in conjunction with ASA
and/or clopidogrel is associated with an
increased risk of bleeding and should be
monitored closely. (Level of Evidence: A)
CLASS IIB
 Warfarin either without (INR 2.5 to 3.5) or
with low-dose ASA (75 to 81 mg per d; INR
2.0 to 2.5) may be reasonable for patients at
high CAD risk and low bleeding risk who
do not require or are intolerant of
clopidogrel. (Level of Evidence: B)
Special Groups
WOMEN CLASS I
 1. Women with UA/NSTEMI should be managed
with the same pharmacological therapy as men
both in the hospital and for secondary prevention,
with attention to antiplatelet and anticoagulant
doses based on weight and renal function; doses of
renally cleared medications should be based on
estimated creatinine clearance. (Level of Evidence:
B)
 2. Recommended indications for noninvasive
testing in women with UA/NSTEMI are
similar to those for men. (Level of Evidence: B)
 3. For women with high-risk features,
recommendations for invasive strategy are
similar to those of men. (Level of Evidence:
B)
 4.
In women with low-risk features, a
conservative strategy is recommended. (Level
of Evidence: B)
Diabetes Mellitus
(UPDATED)
Class I
 1. Medical treatment in the acute phase of
UA/NSTEMI and decisions on whether to
perform stress testing, angiography, and
revascularization should be similar in
patients with and without diabetes mellitus.
(Level of Evidence: A)
 2. In all patients with diabetes mellitus and
UA/NSTEMI, attention should be directed
toward aggressive glycemic management in
accordance with current standards of
diabetes care endorsed by the American
Diabetes Association and the American
College of Endocrinology.
 Goals
of therapy should include a
preprandial glucose target of less than 110
mg per dL and a maximum daily target of
less than 180 mg per dL.
 The postdischarge goal of therapy should
be HbA1C less than 7%, which should be
addressed by primary care and cardiac
caregivers at every visit. (Level of Evidence:
B)
 3.
An intravenous platelet GP IIb/IIIa
inhibitor should be administered for patients
with diabetes mellitus as recommended for all
UA/NSTEMI patients (Section 3.2). (Level of
Evidence: A) The benefit may be enhanced in
patients with diabetes mellitus. (Level of
Evidence: B)
CLASS IIA
 1. For patients with UA/NSTEMI and
multivessel disease, CABG with use of the
internal mammary arteries can be beneficial
over PCI in patients being treated for
diabetes mellitus. (Level of Evidence: B)
 2. Percutaneous coronary intervention is
reasonable for UA/NSTEMI patients with
diabetes mellitus with single-vessel disease
and inducible ischemia. (Level of Evidence:
B
 3. In patients with UA/NSTEMI and diabetes
mellitus, it is reasonable to administer
aggressive insulin therapy to achieve a glucose
less than 150 mg per dL during the first 3
hospital (intensive care unit) days and between
80 and 110 mg per dL thereafter whenever
possible. (Level of Evidence: B)
Post-CABG
Patients
Class I
 1. Medical treatment for UA/NSTEMI
patients after CABG should follow the same
guidelines as for non–post-CABG patients
with UA/NSTEMI. (Level of Evidence: C)
 2. Because of the many anatomic possibilities
that might be responsible for recurrent
ischemia, there should be a low threshold for
angiography in post-CABG patients with
UA/NSTEMI. (Level of Evidence: C)
Class IIa
 1.
Repeat CABG is reasonable for
UA/NSTEMI patients with multiple SVG
stenoses, especially when there is significant
stenosis of a graft that supplies the LAD.
 Percutaneous
coronary
intervention
is
reasonable for focal saphenous vein stenosis.
(Level of Evidence: C) (Note that an
intervention on a native vessel is generally
preferable to that on a vein graft that supplies
the same territory, if possible.)
 2. Stress testing with imaging in UA/NSTEMI
post- CABG patients is reasonable. (Level of
Evidence: C)
Older Adults
Class I
 1. Older patients with UA/NSTEMI should
be evaluated for appropriate acute and longterm therapeutic interventions in a similar
manner
as
younger
patients
with
UA/NSTEMI. (Level of Evidence: A)
 2. Decisions on management of older patients
with UA/ NSTEMI should not be based solely
on chronologic age but should be patientcentered, with consideration given to general
health, functional and cognitive status,
comorbidities, life expectancy, and patient
preferences and goals. (Level of Evidence: B)
 3. Attention should be given to appropriate
dosing (i.e., adjusted by weight and
estimated
creatinine
clearance)
of
pharmacological agents in older patients
with UA/ NSTEMI, because they often have
altered pharmacokinetics
 (due to reduced muscle mass, renal and/or
hepatic dysfunction, and reduced volume of
distribution)
and
pharmacodynamics
(increased risks of hypotension and
bleeding). (Level of Evidence: B)
 4. Older UA/NSTEMI patients face increased
early procedural risks with revascularization
relative to younger patients, yet the overall
benefits from invasive strategies are equal to
or perhaps greater in older adults and are
recommended. (Level of Evidence: B)
 5. Consideration should be given to patient
and family preferences, quality-of-life
issues,
end-of-life
preferences,
and
sociocultural differences in older patients
with UA/NSTEMI. (Level of Evidence: C)
Chronic Kidney
Disease
(UPDATED)
Class I
 1. Creatinine clearance should be estimated
in UA/ NSTEMI patients, and the doses of
renally cleared drugs should be adjusted
appropriately. (Level of Evidence: B)
 2.
In chronic kidney disease patients
undergoing angiography, isosmolar contrast
agents are indicated and are preferred.
(Level of Evidence: A)
Cocaine and
Methampheta
mine Users
CLASS I
 1.
Administration of sublingual or
intravenous NTG and intravenous or oral
calcium channel blockers is recommended
for patients with ST-segment elevation or
depression that accompanies ischemic chest
discomfort after cocaine use. (Level of
Evidence: C)
 2. Immediate coronary angiography, if
possible, should be performed in patients
with ischemic chest discomfort after cocaine
use whose ST segments remain elevated
after NTG and calcium channel blockers;
PCI is recommended if occlusive thrombus
is detected. (Level of Evidence: C)
 3. Fibrinolytic therapy is useful in patients
with ischemic chest discomfort after cocaine
use if ST segments remain elevated despite
NTG and calcium channel blockers, if there
are no contraindications, and if coronary
angiography is not possible. (Level of
Evidence: C)
Class IIa
 1. Administration of NTG or oral calcium
channel blockers can be beneficial for patients
with normal ECGs or minimal ST-segment
deviation suggestive of ischemia after cocaine
use. (Level of Evidence: C)
 2. Coronary angiography, if available, is
probably recommended for patients with
ischemic chest discomfort after cocaine use
with ST-segment depression or isolated Twave changes not known to be previously
present and who are unresponsive to NTG
and calcium channel blockers. (Level of
Evidence: C)
 3. Management of UA/NSTEMI patients with
methamphetamine use similar to that of
patients with cocaine use is reasonable. (Level
of Evidence: C)
Class IIb
 Administration of combined alpha- and beta-
blocking agents (e.g., labetalol) may be
reasonable for patients after cocaine use with
hypertension (systolic blood pressure greater
than 150 mm Hg)
 or those with sinus tachycardia (pulse greater
than 100 beats per min) provided that the
patient has received a vasodilator, such as
NTG or a calcium channel blocker, within
close temporal proximity (i.e., within the
previous hour). (Level of Evidence: C)
Class III
 Coronary angiography is not recommended in
patients with chest pain after cocaine use
without ST-segment or T-wave changes and
with a negative stress test and cardiac
biomarkers. (Level of Evidence: C)
Variant
(Prinzmetals) Angina
Class I
 1. Diagnostic investigation is indicated in
patients with a clinical picture suggestive of
coronary spasm, with investigation for the
presence of transient myocardial ischemia and
ST-segment elevation during chest pain. (Level
of Evidence: A)
 2. Coronary angiography is recommended in
patients with episodic chest pain accompanied
by transient ST-segment elevation. (Level of
Evidence: B)
 3. Treatment with nitrates and calcium
channel blockers is recommended in patients
with variant angina whose coronary
angiogram shows no or nonobstructive
coronary artery lesions.
 Risk factor modification is recommended, with
patients with atherosclerotic lesions considered
to be at higher risk. (Level of Evidence: B)
Class IIb
 1. Percutaneous coronary intervention may be
considered in patients with chest pain and
transient St segment elevation and a
significant coronary artery stenosis. (Level of
Evidence: B)
 2. Provocative testing may be considered in
patients with no significant angiographic CAD
and no documentation of transient ST-segment
elevation when clinically relevant symptoms
possibly explained by coronary artery spasm
are present. (Level of Evidence: C)
Class III
 Provocative testing is not recommended in
patients with variant angina and high-grade
obstructive stenosis on coronary angiography.
(Level of Evidence: B)
Cardiovascular
“Syndrome X”
Class I
 1.
Medical therapy with nitrates, beta
blockers, and calcium channel blockers, alone
or in combination, is recommended in patients
with cardiovascular syndrome X. (Level of
Evidence: B)
 2. Risk factor reduction is recommended in
patients with cardiovascular syndrome X.
(Level of Evidence: B)
CLASS IIB
 1. Intracoronary ultrasound to assess the
extent of atherosclerosis and rule out missed
obstructive lesions may be considered in
patients with syndrome X. (Level of
Evidence: B)
 2. If no ECGs during chest pain are available
and coronary spasm cannot be ruled out,
coronary angiography and provocative
testing with acetylcholine, adenosine, or
methacholine and 24-h ambulatory ECG
may be considered. (Level of Evidence: C)
 3. If coronary angiography is performed and
does not reveal a cause of chest discomfort,
and if syndrome X is suspected, invasive
physiological assessment (i.e., coronary flow
reserve measurement) may be considered.
(Level of Evidence: C)
 4. Imipramine or aminophylline may be
considered in patients with syndrome X for
continued pain despite implementation of
Class I measures. (Level of Evidence: C)
 5.
Transcutaneous
electrical
nerve
stimulation and spinal cord stimulation for
continued pain despite the implementation
of Class I measures may be considered for
patients with syndrome X. (Level of
Evidence: B)
Class III
 Medical therapy with nitrates, beta blockers,
and calcium channel blockers for patients with
noncardiac chest pain is not recommended.
(Level of Evidence: C)
Takotsubo Cardiomyopathy
 A disorder, or group of disorders, with several
names (stress induced cardiomyopathy,
transient LV apical ballooning, Takotsubo
cardiomyopathy, and broken heart syndrome)
is an uncommon but increasingly reported
cause of ACS.
 Takotsubo cardiomyopathy is noteworthy for
the absence of obstructive coronary artery
disease, typical precipitation by intense
psychological or emotional stress, and
predominant occurrence in postmenopausal
women.
 The characteristic finding of apical LV
ballooning is seen on left ventriculography or
echocardiography, with transient ST elevation
or deep T-wave inversions on the surface
ECG.
 Despite the presence of positive cardiac
biomarkers and frequent hemodynamic
compromise or even cardiogenic shock, almost
all patients recover completely, typically with
normal wall motion within 1 to 4 weeks